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Katada Y, Nakagawa S, Nagao M, Umemura K, Itohara K, Nishikawa A, Hashi S, Katsube Y, Hira D, Ohsumi A, Nakajima D, Date H, Terada T. Trough ganciclovir concentration as predictor of leukopenia in lung transplant recipients receiving valganciclovir prophylaxis. Transpl Infect Dis 2023; 25:e14141. [PMID: 37639301 DOI: 10.1111/tid.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Valganciclovir is the first-line agent for Cytomegalovirus prophylaxis after lung transplantation. However, its use is associated with a relatively high risk of hematological toxicity. This study aimed to investigate the relationship between trough ganciclovir concentration and hematologic toxicity in lung transplantation patients receiving valganciclovir prophylaxis, and identify factors that affect ganciclovir pharmacokinetics in this population. METHODS This prospective observational study included 24 lung transplant patients receiving valganciclovir prophylaxis. The cutoff value of trough ganciclovir concentration was estimated using receiver operating characteristic analysis in leukopenia grade 3 and higher. Population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling program. RESULTS The trough ganciclovir concentration was significantly higher in the group with leukopenia grades 3 or higher than in the group with grades less than or equal to 2 (1605.7 ± 860.1 ng/mL [n = 3] vs. 380.5 ± 175.8 ng/mL (n = 21), p < .001). The cutoff value of trough ganciclovir concentration for predicting greater than or equal to grade 3 leukopenia was estimated as 872.0 ng/mL. Creatinine clearance and lung re-transplantation were found to have a significant impact on the total body clearance of valganciclovir. Ganciclovir clearance was decreased in patients with reduced creatine clearance or re-transplantation. CONCLUSION These results suggest that higher ganciclovir trough concentrations are associated with an increased risk of leukopenia grade 3 or higher, and that creatinine clearance and lung re-transplantation affected the pharmacokinetics of ganciclovir.
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Affiliation(s)
- Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
- Department of Infection Control and Prevention, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Miki Nagao
- Department of Infection Control and Prevention, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Asami Nishikawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
- Department of Infection Control and Prevention, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Sachiyo Hashi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Yurie Katsube
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
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Yang W, Mak W, Gwee A, Gu M, Wu Y, Shi Y, He Q, Xiang X, Han B, Zhu X. Establishment and Evaluation of a Parametric Population Pharmacokinetic Model Repository for Ganciclovir and Valganciclovir. Pharmaceutics 2023; 15:1801. [PMID: 37513988 PMCID: PMC10386724 DOI: 10.3390/pharmaceutics15071801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Ganciclovir and valganciclovir are used for prophylaxis and treatment of cytomegalovirus infection. However, there is great interindividual variability in ganciclovir's pharmacokinetics (PK), highlighting the importance of individualized dosing. To facilitate model-informed precision dosing (MIPD), this study aimed to establish a parametric model repository of ganciclovir and valganciclovir by summarizing existing population pharmacokinetic information and analyzing the sources of variability. (2) Methods: A total of four databases were searched for published population PK models. We replicated these models, evaluated the impact of covariates on clearance, calculated the probability of target attainment for each model based on a predetermined dosing regimen, and developed an area under the concentration-time curve (AUC) calculator using maximum a posteriori Bayesian estimation. (3) Results: A total of 16 models, one- or two-compartment models, were included. The most significant covariates were body size (weight and body surface area) and renal function. The results show that 5 mg/kg/12 h of ganciclovir could make the AUC0-24h within 40-80 mg·h/L for 50.03% pediatrics but cause AUC0-24h exceeding the exposure thresholds for toxicity (120 mg·h/L) in 51.24% adults. (4) Conclusions: Dosing regimens of ganciclovir and valganciclovir should be adjusted according to body size and renal function. This model repository has a broad range of potential applications in MIPD.
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Affiliation(s)
- Wenyu Yang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
- Department of Pharmacy, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Wenyao Mak
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Amanda Gwee
- Department of General Medicine, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Meng Gu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
- Department of Pharmacy, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Yue Wu
- Department of Clinical Pharmacy, Shenzhen Children's Hospital Affiliated to Shantou University Medical College, Shenzhen 518038, China
| | - Yufei Shi
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Qingfeng He
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Bing Han
- Department of Pharmacy, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai 201203, China
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3
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Selby PR, Heffernan AJ, Yeung D, Warner MS, Peake SL, Hahn U, Wallis SC, Mcwhinney B, Ungerer JPJ, Shakib S, Roberts JA. Population Pharmacokinetics of Ganciclovir in Allogeneic Hematopoietic Stem Cell Transplant Patients. Antimicrob Agents Chemother 2023; 67:e0155022. [PMID: 36815858 PMCID: PMC10019199 DOI: 10.1128/aac.01550-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/26/2023] [Indexed: 02/24/2023] Open
Abstract
Treatment of cytomegalovirus (CMV) infection in allogeneic hematopoietic stem cell transplantation (alloHCT) patients with ganciclovir is complicated by toxicity and resistance. This study aimed to develop an intravenous ganciclovir population pharmacokinetic model for post-alloHCT patients and to determine dosing regimens likely to achieve suggested therapeutic exposure targets. We performed a prospective observational single-center pharmacokinetic study in adult alloHCT patients requiring treatment with intravenous ganciclovir for CMV viremia or disease. Samples were analyzed using a validated ultraperformance liquid chromatography method. Population pharmacokinetic analysis and Monte Carlo simulations (n = 1000) were performed using Pmetrics for R. Twenty patients aged 18 to 69 years were included in the study. A 2-compartment model with linear elimination from the central compartment and between occasion variability best described the data. Incorporating creatinine clearance (CLCR) estimated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and presence of continuous renal replacement therapy as covariates for ganciclovir clearance improved the model. Compared to current dosing recommendations, simulations demonstrated loading doses were required to achieve a target AUC24 of 80 to 120 mg.h/L on day 1 of induction therapy. Increased individualization of post-loading induction and maintenance doses based on CLCR is required to achieve the suggested exposures for efficacy (AUC24 >80/>40 mg.h/L for induction/maintenance) while remaining below the exposure thresholds for toxicity (AUC24 <120/<60 mg.h/L for induction/maintenance). Intravenous ganciclovir dosing in alloHCT patients can be guided by CLCR estimated by CKD-EPI. Incorporation of loading doses into induction dosing regimens should be considered for timely achievement of currently suggested exposures.
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Affiliation(s)
- Philip R. Selby
- School of Medicine, University of Adelaide, Adelaide, Australia
- Pharmacy Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Aaron J. Heffernan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David Yeung
- School of Medicine, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Haematology Unit, Royal Adelaide Hospital, Adelaide, Australia
- Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Morgyn S. Warner
- School of Medicine, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Sandra L. Peake
- School of Medicine, University of Adelaide, Adelaide, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Uwe Hahn
- School of Medicine, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Haematology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Steven C. Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Brett Mcwhinney
- Pathology Queensland, Queensland Health, Brisbane, Australia
| | - Jacobus P. J. Ungerer
- Pathology Queensland, Queensland Health, Brisbane, Australia
- Faculty of Health and Behavioural Science, University of Queensland, Brisbane, Australia
| | - Sepehr Shakib
- School of Medicine, University of Adelaide, Adelaide, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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4
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Märtson AG, Edwina AE, Kim HY, Knoester M, Touw DJ, Sturkenboom MGG, Alffenaar JWC. Therapeutic Drug Monitoring of Ganciclovir: Where Are We? Ther Drug Monit 2022; 44:138-147. [PMID: 34610621 PMCID: PMC8746890 DOI: 10.1097/ftd.0000000000000925] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ganciclovir is the mainstay of therapy for the prophylaxis and treatment of Cytomegalovirus. However, therapy with this antiviral agent is hindered by side effects such as myelosuppression, which often leads to therapy cessation. Underdosing, as an attempt to prevent side effects, can lead to drug resistance and therapy failure. Therapeutic drug monitoring (TDM) has been used to overcome these problems. The purpose of this narrative review was to give an overview of ganciclovir TDM, available assays, population pharmacokinetic models, and discuss the current knowledge gaps. METHODS For this narrative review, a nonsystematic literature search was performed on the PubMed database in April 2021. The following search terms were used: ganciclovir, valganciclovir, pharmacokinetics, pharmacodynamics, population pharmacokinetics, therapeutic drug monitoring, bioassay, liquid chromatography coupled with tandem mass spectrometry, liquid chromatography, chromatography, spectrophotometry, and toxicity. In addition, the reference lists of the included articles were screened. RESULTS The most common bioanalysis method identified was liquid chromatography coupled with tandem mass spectrometry. There are different models presenting ganciclovir IC50; however, establishing a pharmacokinetic/pharmacodynamic target for ganciclovir based on preclinical data is difficult because there are no studies combining dynamic drug exposure in relation to inhibition of viral replication. The data on ganciclovir TDM show large interindividual variability, indicating that TDM may play a role in modifying the dose to reduce toxicity and prevent treatment failure related to low concentrations. The main hurdle for implementing TDM is the lack of robust data to define a therapeutic window. CONCLUSIONS Although the pharmacokinetics (PK) involved is relatively well-described, both the pharmacodynamics (PD) and pharmacokinetic/pharmacodynamic relationship are not. This is because the studies conducted to date have mainly focused on estimating ganciclovir exposure, and owing to the limited therapeutic options for CMV infections, future studies on ganciclovir are warranted.
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Affiliation(s)
- Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Angela E. Edwina
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Marjolein Knoester
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; and
| | - Daan J. Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marieke G. G. Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jan-Willem C. Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
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5
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Farrar JE, Mueller SW, Stevens V, Kiser TH, Taleb S, Reynolds PM. Correlation of antimicrobial fraction unbound and sieving coefficient in critically ill patients on continuous renal replacement therapy: a systematic review. J Antimicrob Chemother 2021; 77:310-319. [DOI: 10.1093/jac/dkab396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/06/2021] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Fraction unbound has been used as a surrogate for antimicrobial sieving coefficient (SC) to predict extracorporeal clearance in critically ill patients on continuous renal replacement therapy (CRRT), but this is based largely on expert opinion.
Objectives
To examine relationships between package insert-derived fraction unbound (Fu-P), study-specific fraction unbound (Fu-S), and SC in critically ill patients receiving CRRT.
Methods
English-language studies containing patient-specific in vivo pharmacokinetic parameters for antimicrobials in critically ill patients requiring CRRT were included. The primary outcome included correlations between Fu-S, Fu-P, and SC. Secondary outcomes included correlations across protein binding quartiles, serum albumin, and predicted in-hospital mortality, and identification of predictors for SC through multivariable analysis.
Results
Eighty-nine studies including 32 antimicrobials were included for analysis. SC was moderately correlated to Fu-S (R2 = 0.55, P < 0.001) and Fu-P (R2 = 0.41, P < 0.001). SC was best correlated to Fu-S in first (<69%) and fourth (>92%) quartiles of fraction unbound and above median albumin concentrations of 24.5 g/L (R2 = 0.71, P = 0.07). Conversely, correlation was weaker in patients with mortality estimates greater than the median of 55% (R2 = 0.06, P = 0.84). SC and Fu-P were also best correlated in the first quartile of antimicrobial fraction unbound (R2 = 0.66, P < 0.001). Increasing Fu-P, flow rate, membrane surface area, and serum albumin, and decreasing physiologic charge significantly predicted increasing SC.
Conclusions
Fu-S and Fu-P were both reasonably correlated to SC. Caution should be taken when using Fu-S to calculate extracorporeal clearance in antimicrobials with 69%–92% fraction unbound or with >55% estimated in-hospital patient mortality. Fu-P may serve as a rudimentary surrogate for SC when Fu-S is unavailable.
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Affiliation(s)
- Julie E. Farrar
- Auburn University Harrison School of Pharmacy, 650 Clinic Dr, Mobile, AL 36688, USA
| | - Scott W. Mueller
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Victoria Stevens
- University of Colorado Hospital, 12505 E 16th Ave, Aurora, CO 80045, USA
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Sim Taleb
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
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Jarrell AS, Crow JR, Strout SE, Kruer RM, Toman LP, Dioverti-Prono MV, Lees L, Avery RK, Marzinke MA. Valganciclovir Dosing for Cytomegalovirus Prophylaxis in Solid-organ Transplant Recipients on Continuous Veno-venous Hemodialysis. Clin Infect Dis 2021; 73:101-106. [PMID: 32379860 DOI: 10.1093/cid/ciaa537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/01/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optimal valganciclovir dosing for cytomegalovirus (CMV) prophylaxis in solid-organ transplant (SOT) patients on continuous veno-venous hemodialysis (CVVHD) is not known. Ganciclovir trough concentrations ≥0.60 μg/mL have been suggested for CMV prophylaxis. This study was conducted to determine if valganciclovir 450 mg enterally every 24 hours achieves ganciclovir trough concentrations ≥0.60 μg/mL in patients on CVVHD. METHODS This single-center, prospective, open-label, pharmacokinetic study included adult SOT patients admitted to an intensive care unit from March 2018 to June 2019 on CVVHD. All patients were receiving valganciclovir 450 mg enterally every 24 hours for CMV prophylaxis prior to enrollment. Each patient had a peak and trough sample drawn at steady state. RESULTS Ten SOT patients were included in the study (6 liver, 1 simultaneous liver-kidney, 2 bilateral lung, 1 heart). The mean ± SD age was 51.8 ± 14.0 years, and average body mass index was 27 ± 6.9 kg/m2. Ganciclovir trough concentrations ranged from 0.31 to 3.16 μg/mL, and 80% of participants have trough concentrations ≥0.60 μg/mL. No patients had documented neutropenia while on valganciclovir and CVVHD; 60% of patients had significant thrombocytopenia. CONCLUSIONS Valganciclovir 450 mg enterally every 24 hours achieved ganciclovir trough concentrations ≥0.60 μg/mL in most patients on CVVHD, similar to those reported with intravenous ganciclovir for prophylaxis in this population. Based on these data, valganciclovir may require dosing every 24 hours to achieve concentrations equivalent to ganciclovir. Neutropenia did not occur in the study period. Thrombocytopenia was common and likely multifactorial.
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Affiliation(s)
- Andrew S Jarrell
- The Johns Hopkins Hospital, Department of Pharmacy, Division of Critical Care and Surgery, Baltimore, Maryland, USA
| | - Jessica R Crow
- The Johns Hopkins Hospital, Department of Pharmacy, Division of Critical Care and Surgery, Baltimore, Maryland, USA
| | - Sara E Strout
- The Johns Hopkins Hospital, Department of Pharmacy, Division of Critical Care and Surgery, Baltimore, Maryland, USA
| | - Rachel M Kruer
- Indiana University Health-Adult Academic Health Center, Department of Pharmacy, Indianapolis, Indiana, USA
| | - Lindsey P Toman
- The Johns Hopkins Hospital, Department of Pharmacy, Division of Critical Care and Surgery, Baltimore, Maryland, USA
| | - Maria V Dioverti-Prono
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
| | - Laura Lees
- The Johns Hopkins Hospital, Department of Pharmacy, Division of Critical Care and Surgery, Baltimore, Maryland, USA
| | - Robin K Avery
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Department of Pathology, Baltimore, Maryland, USA.,Johns Hopkins University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Baltimore, Maryland, USA
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Abstract
BACKGROUND The pharmacokinetic (PK) data of ganciclovir (GCV), a first-line antiviral treatment for cytomegalovirus infections, in critically ill patients are limited. This study aimed at characterizing GCV population PK and interindividual variability (IIV) in intensive care unit (ICU) patients. Secondary objectives were to identify patient characteristics responsible for IIV and simulate GCV exposure for different dosing regimens. METHOD In this retrospective observational study, clinical data and serum GCV levels were collected from ICU patients on intravenous GCV. PK modeling, covariate analyses, and explorative Monte Carlo dosing simulations (MCS) were performed using nonlinear mixed-effects modeling. Bootstrap and visual predictive checks were used to determine model adequacy. RESULTS In total, 128 GCV measurements were obtained from 34 patients. GCV PK conformed to a 1-compartment model with first-order elimination. After multivariate analyses, only the estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (P < 0.001) was included as a covariate. In the final model, the estimated clearance (CL) and volume of distribution (V1) were 2.3 L/h and 42 L, respectively, for a patient with the median CKD-EPI of the population (65 mL/min per 1.73 m). The association between CKD-EPI and CL decreased the residual variability from 0.56 to 0.43 and V1-IIV from 114% to 80%, whereas CL-IIV changed from 43% to 47%. MCS revealed that a substantial number of patients may not achieve the GCV PK/pharmacodynamic target trough level (>1.5 mg/L) when administering the label-recommended dose reductions for patients with CKD-EPI <50 mL/min. CONCLUSIONS A large IIV was observed in GCV PK among ICU patients. CKD-EPI could partially explain the IIV, although a large part of the variability remains unclear. MCS suggested that recommended dose reductions for CKD-EPI <50 mL/min may lead to subtherapeutic plasma GCV levels in these patients.
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8
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Ganciclovir Therapy for CMV Viremia in a Patient on VV ECMO With COVID-19 After Treatment With Tocilizumab. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000001035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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9
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Valganciclovir-Ganciclovir Use and Systematic Therapeutic Drug Monitoring. An Invitation to Antiviral Stewardship. Antibiotics (Basel) 2021; 10:antibiotics10010077. [PMID: 33467490 PMCID: PMC7831032 DOI: 10.3390/antibiotics10010077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
Abstract
Valganciclovir (VGCV) and ganciclovir (GCV) doses must be adjusted according to indication, renal function and weight. No specific therapeutic exposure values have been established. We aimed to evaluate the adequacy of VGCV/GCV doses, to assess the interpatient variability in GCV serum levels, to identify predictive factors for this variability and to assess the clinical impact. This is a prospective study at a tertiary institution including hospitalized patients receiving VGCV/GCV prophylaxis or treatment. Adequacy of the antiviral dose was defined according to cytomegalovirus guidelines. Serum levels were determined using High-Performance Liquid Chromatography. Blood samples were drawn at least 3 days after antiviral initiation. Outcome was considered favorable if there was no evidence of cytomegalovirus infection during prophylaxis or when a clinical and microbiological resolution was attained within 21 days of treatment and no need for drug discontinuation due to toxicity. Seventy consecutive patients [74.3% male/median age: 59.2 years] were included. VGCV was used in 25 patients (35.7%) and GCV in 45 (64.3%). VGCV/GCV initial dosage was deemed adequate in 47/70 cases (67.1%), lower than recommended in 7/70 (10%) and higher in 16/70 (22.9%). Large inter-individual variability of serum levels was observed, with median trough levels of 2.3 mg/L and median peak levels of 7.8 mg/L. Inadequate dosing of VGCV/GCV and peak levels lower than 8.37 or greater than 11.86 mg/L were related to poor outcome. Further studies must be performed to confirm these results and to conclusively establish if VGCV/GCV therapeutic drug monitoring could be useful to improve outcomes in specific clinical situations.
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10
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Ho SA, Slavin M, Roberts JA, Yong M. Optimization of Ganciclovir use in allogeneic hematopoietic cell transplant recipients - the role of therapeutic drug monitoring. Expert Rev Anti Infect Ther 2020; 19:707-718. [PMID: 33201745 DOI: 10.1080/14787210.2021.1851193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Cytomegalovirus (CMV) is an opportunistic infectious complication that can occur after allogeneic hematopoietic cell transplantation (HCT). The mainstay of treatment and prevention of this infection is ganciclovir and its ester prodrug valganciclovir. There is conflicting evidence on the clinical utility of routine ganciclovir therapeutic drug monitoring (TDM) as a means to optimize treatment.Areas covered: This review aims to describe the current knowledge of the pharmacokinetic and pharmacodynamic characteristics of ganciclovir and valganciclovir, and to explore the evidence and challenges surrounding ganciclovir TDM within the allogeneic HCT cohort.Expert opinion: Ganciclovir TDM is important to optimize efficacy in selected patient groups where there are variable pharmacokinetic factors or inadequate response to treatment. However, defined pharmacokinetic exposures which correlate with treatment efficacy and toxicity remain elusive. Prospective clinical studies in specific patient groups are required to clarify this issue. Alternative TDM targets such as the intracellular ganciclovir triphosphate should be explored as they may prove to have better correlation with clinical outcomes and adverse effects. With recent advances in CMV immune monitoring, novel approaches integrating TDM with specific CMV immune phenotyping in a predictive model will be advantageous in optimizing ganciclovir dosing by combining TDM with a risk stratification approach.
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Affiliation(s)
- Su Ann Ho
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia
| | - Monica Slavin
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Services Department, Royal Melbourne Hospital, Parkville VIC, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Michelle Yong
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Services Department, Royal Melbourne Hospital, Parkville VIC, Australia
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Ghribi F, Sehailia M, Aoudjit L, Touahra F, Zioui D, Boumechhour A, Halliche D, Bachari K, Benmaamar Z. Solar-light promoted photodegradation of metronidazole over ZnO-ZnAl2O4 heterojunction derived from 2D-layered double hydroxide structure. J Photochem Photobiol A Chem 2020. [DOI: 10.1016/j.jphotochem.2020.112510] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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12
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Li L, Li X, Xia Y, Chu Y, Zhong H, Li J, Liang P, Bu Y, Zhao R, Liao Y, Yang P, Lu X, Jiang S. Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy. Front Pharmacol 2020; 11:786. [PMID: 32547394 PMCID: PMC7273837 DOI: 10.3389/fphar.2020.00786] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.
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Affiliation(s)
- Lu Li
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Li
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Yanzhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haili Zhong
- Department of Pharmacy, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yishan Bu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Rui Zhao
- School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yun Liao
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Saiping Jiang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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Murphy M, Chamberlain A, Tang P, Turpin B, Danziger-Isakov L. Paediatric ganciclovir dosing in extracorporeal membrane oxygenation: Is standard dosing good enough? J Clin Pharm Ther 2019; 45:218-220. [PMID: 31545518 DOI: 10.1111/jcpt.13051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/29/2019] [Accepted: 09/02/2019] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Ganciclovir is a first-line antiviral agent to treat cytomegalovirus disease in immunocomprimised patients. Ganciclovir pharmacokinetics in ECMO is unknown. CASE DESCRIPTION A 6-year-old with a stage IV extra-renal rhabdoid tumor with respiratory failure leading to extracorporeal membrane oxygenation had increasing serum CMV DNAemia while on ganciclovir. WHAT IS NEW AND CONCLUSION This is the first case report of ganciclovir pharmacokinetics in either paediatric or adult ECMO populations. Recommended dosing provided a low, subtherapeutic AUC24 with an associated increase CMV viral load. Higher doses of ganciclovir may be required in ECMO patients, especially without concurrent CRRT.
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Affiliation(s)
- Mark Murphy
- Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrea Chamberlain
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter Tang
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brian Turpin
- Division of Pediatric Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lara Danziger-Isakov
- Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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14
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Märtson AG, Touw D, Damman K, Bakker M, Oude Lansink-Hartgring A, van der Werf T, Knoester M, Alffenaar JWC. Ganciclovir Therapeutic Drug Monitoring: A Case Series. Ther Drug Monit 2019; 41:107-110. [PMID: 30883503 PMCID: PMC6426343 DOI: 10.1097/ftd.0000000000000598] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article presents 3 cases of immunocompromised patients for whom therapeutic drug monitoring of ganciclovir in combination with cytomegalovirus viral load measurement was used to guide treatment. The first patient is diagnosed with thymoma A, the second is a heart transplant recipient, and the third is an HIV-positive patient. These patients were all diagnosed with cytomegalovirus and treated with ganciclovir. Our case studies illustrate how therapeutic drug monitoring-guided dosing can be helpful in the management of these complex cases.
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Affiliation(s)
| | - Daan Touw
- Departments of Clinical Pharmacy and Pharmacology
| | | | | | | | | | - Marjolein Knoester
- Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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15
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Abstract
Ganciclovir is synthetic nucleoside analog of guanine closely related to acyclovir but has greater activity against cytomegalovirus. This comprehensive profile on ganciclovir starts with a description of the drug: nomenclature, formulae, chemical structure, elemental composition, and appearance. The uses and application of the drug are explained. The methods that were used for the preparation of ganciclovir are described and their respective schemes are outlined. The methods which were used for the physical characterization of the dug are: ionization constant, solubility, X-ray powder diffraction pattern, crystal structure, melting point, and differential scanning calorimetry. The chapter contains the spectra of the drug: ultraviolet spectrum, vibrational spectrum, nuclear magnetic resonance spectra, and the mass spectrum. The compendial methods of analysis of ganciclovir include the United States Pharmacopeia methods. Other methods of analysis that were reported in the literature include: high-performance liquid chromatography alone or with mass spectrometry, electrophoresis, spectrophotometry, voltammetry, chemiluminescence, and radioimmunoassay. Biological investigation on the drug includes: pharmacokinetics, metabolism, bioavailability, and biological analysis. Reviews on the methods used for preparation or for analysis of the drug are provided. The stability of the drug in various media and storage conditions is reported. More than 240 references are listed at the end of the chapter.
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Affiliation(s)
- Abdullah A Al-Badr
- College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Tariq D S Ajarim
- College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
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16
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Jager NGL, van Hest RM, Lipman J, Taccone FS, Roberts JA. Therapeutic drug monitoring of anti-infective agents in critically ill patients. Expert Rev Clin Pharmacol 2016; 9:961-79. [PMID: 27018631 DOI: 10.1586/17512433.2016.1172209] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Initial adequate anti-infective therapy is associated with significantly improved clinical outcomes for patients with severe infections. However, in critically ill patients, several pathophysiological and/or iatrogenic factors may affect the pharmacokinetics of anti-infective agents leading to suboptimal drug exposure, in particular during the early phase of therapy. Therapeutic drug monitoring (TDM) may assist to overcome this problem. We discuss the available evidence on the use of TDM in critically ill patient populations for a number of anti-infective agents, including aminoglycosides, β-lactams, glycopeptides, antifungals and antivirals. Also, we present the available evidence on the practices of anti-infective TDM and describe the potential utility of TDM to improve treatment outcome in critically ill patients with severe infections. For aminoglycosides, glycopeptides and voriconazole, beneficial effects of TDM have been established on both drug effectiveness and potential side effects. However, for other drugs, therapeutic ranges need to be further defined to optimize treatment prescription in this setting.
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Affiliation(s)
- Nynke G L Jager
- a Department of Pharmacy , Academic Medical Center , Amsterdam , The Netherlands
| | - Reinier M van Hest
- a Department of Pharmacy , Academic Medical Center , Amsterdam , The Netherlands
| | - Jeffrey Lipman
- b Burns Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,c Departments of Pharmacy and Intensive Care , Royal Brisbane and Women's Hospital , Brisbane , Australia
| | - Fabio S Taccone
- d Department of Intensive Care, Hopital Erasme , Université Libre de Bruxelles (ULB) , Brussels , Belgium
| | - Jason A Roberts
- b Burns Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,c Departments of Pharmacy and Intensive Care , Royal Brisbane and Women's Hospital , Brisbane , Australia.,e School of Pharmacy , The University of Queensland , Brisbane , Australia
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Stockmann C, Roberts JK, Knackstedt ED, Spigarelli MG, Sherwin CM. Clinical pharmacokinetics and pharmacodynamics of ganciclovir and valganciclovir in children with cytomegalovirus infection. Expert Opin Drug Metab Toxicol 2014; 11:205-19. [PMID: 25428442 DOI: 10.1517/17425255.2015.988139] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Among infants and immunocompromised children cytomegalovirus (CMV) is associated with significant morbidity and mortality. AREAS COVERED This review describes the clinical pharmacokinetics and pharmacodynamics of ganciclovir and valganciclovir for the treatment and prevention of CMV infection in children. EXPERT OPINION A 24-h ganciclovir area under the concentration versus time curve (AUC₀₋₂₄) of 40 - 60 μg h/ml decreased the risk of CMV infection for adults undergoing CMV prophylaxis. For adults undergoing treatment for active CMV disease, a target AUC₀₋₁₂ of 40 - 60 μg h/ml has been suggested. The applicability of these targets to children remains uncertain; however, with the most sophisticated dosing regimens developed to date only 21% of patients are predicted to reach these targets. Moving forward, identification of optimal pediatric ganciclovir and valganciclovir dosing regimens may involve the use of an externally validated pediatric population pharmacokinetic model for empirical dosing, an optimal sampling strategy for collecting a minimal number of blood samples for each patient and Bayesian updating of the dosing regimen based on an individual patient's pharmacokinetic profile.
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Affiliation(s)
- Chris Stockmann
- University of Utah School of Medicine, Division of Clinical Pharmacology, Department of Pediatrics , 295 Chipeta Way, Salt Lake City, UT 84108 , USA +1 801 587 7404 ; +1 801 585 9410 ;
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Nunez-Nunez M, Bellapart J, O'Donoghue S, McWhinney B, Ungerer JPJ, Lipman J, Roberts JA. Variable ganciclovir concentrations in a critically ill patient receiving continuous renal replacement therapy and plasma exchange? Int J Antimicrob Agents 2014; 43:572-3. [PMID: 24853257 DOI: 10.1016/j.ijantimicag.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/04/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Nunez-Nunez
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Herston, QLD, Australia; UGC Farmacia/UGC Intercentros Enfermedades Infecciosas, Microbiologia y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocio, Seville, Spain
| | | | | | | | | | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Herston, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Herston, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
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